MEDICAL HUMANITIES IN CANADIAN MEDICAL SCHOOLS: Progress, challenges and opportunities

Introduction

Kidd and Connor (2008) documented a diversity ot views as to what constitutes the ‘medical humanities’ (hereafter ‘MH’)—now also widely termed ‘health humanities’ (Atkinson et al. 2015)—noting a lack ot consensus regarding associated best practice teaching approaches in Canadian medical schools. Appendix A summarises information obtained in 2005—2006 from key informants in their study. They described the field as having marginalised status, where a biomedical and evidence-based medicine model has dominated since the 1990s (Mykhalovskiy and Weir 2004). Recognising the heterogeneity and fluidity of the developing field (Hurwitz 2013; Bleakley 2015), we define MH as a field embracing perspectives and approaches across the arts, humanities and social sciences focused on educational goals concerned with the human side of medicine. We note Kidd and Connor’s (2008: 47) definition ot MH as inclusive of content and approaches that encourage “reflection and critical thinking about the human body and mind” and related systems.

Over the past decade, significant advances in medical education have occurred including enhanced emphasis on humanism and professional identity formation (Cruess et al. 2014; Branch 2015; Wald et al. 2015). A shift towards social accountability as a core mandate for medical education was also introduced by the 2010 ‘Future of Medical Education in Canada’ report (AFMC 2009). A recent study of medical school websites and course databases also found evidence of increasing integration of MH teaching in Canadian undergraduate medical programmes (Lam et al. 2015).

In light of these developments, this chapter provides an update regarding the status ofMH in Canadian medical schools, and, we hope, will serve as a template for others seeking to survey a similar field in other geographical locations.

Methods

Setting and participants

Key informants at all 17 Canadian medical schools known to have expert knowledge regarding MH offerings at their medical school, or recommended by their medical school dean, participated in this study. In turn, our research team advertised a wide range of (interdisciplinary expertise.

Data collection

In mid-2014, we conducted a virtual consultation via various medical/health humanities listserves (such as the Arts, Humanities, Social Sciences and Medicine e-listserve) and asked colleagues to suggest questions they believed were relevant to both characterising and understanding MH teaching and learning in medical education. We considered both frequently nominated questions and those most relevant to Canadian medical education. Questions involving brief or closed-ended responses were included in an online survey. Open-ended questions were included in a semi-structured interview guide.

Our survey covered: admission policies, MH disciplines and approaches used in the curriculum, inter-professional learning, co-curricular (or extra-curricular) opportunities, assessment, disciplinary backgrounds of those involved in MH teaching, faculty development, funding and MH website texts. Key informants were also asked about contributing to a centralised Canadian MH resource. Finally, respondents were invited to participate in a 20-minute-long interview about experiences of MH teaching and learning. Data collection occurred over a period of 10 months (beginning 09/2014). Interviews were audiotaped and transcribed. The Mount Sinai Hospital Research Ethics Board (Toronto) approved our research protocol.

Data analysis

We used a mixed-methods approach. We considered survey and interview responses to characterise curricular and co-curricular MH offerings at each school, and summarised these in tables. We used the constant comparative method (Glaser and Strauss 1967) to identify key themes in interview transcripts. In interpreting data we adopted a critical analysis approach, reflexively articulating and exploring our emerging understandings through dialogue (Russell and Kelly 2002; Alvesson and Skoldberg 2009; Green and Thorogood 2013).

Findings

We obtained survey responses from 26 faculty (Kidd and Connor 2008) members at all 17 medical schools, and conducted telephone or in-person interviews with informants at 10 medical schools (nine with those who had also completed the survey, where one person responded to survey questions when they were interviewed and subsequently confirmed our tabulated summary). Although we hoped to connect with at least two representatives from each medical school, due to scheduling and time constraints, this was not possible. We recorded all positive responses when key informants from the same school differed in their survey responses (we used an asterisk [*] to indicate responses provided by only one of two key informants in our summary tables). We assumed that key informants had knowledge of different educational offerings at their medical school.

The lay of the land: key survey findings

Appendix В (Table A36.2) provides an overview of admissions policies and provision of MH teaching at all 17 Canadian medical schools. Thirteen schools considered applicants from a broad range of disciplines (see ‘Open admission’). In relation to curriculum exposure, all schools included MH teaching in the first year, while nine offered MH opportunities in all years of the MD programme.

Twelve schools reported inclusion of arts, humanities and social sciences teaching in the curriculum, and/or as elective offerings (see Appendix В—Table A36.2: ‘MH disciplines, content’—A, H and SS listings). Additional MH-related curricular content and electives were reported for five schools. With respect to arts-based disciplines and approaches, literature/narra- tive and/or reflective exercises were included in all MD programmes. All schools also included content related to bioethics/philosophy, and 15 covered history of medicine topics. Social science (medical anthropology and/or sociology') perspectives were also included in curriculum offerings at 12 schools.

MH teaching was integrated in the core curriculum via mandatory and optional lectures, seminars, small group sessions, activities and assignments (Appendix В—Table A36.2). Stand-alone and longitudinal elective courses were offered at 13 schools. MH curricular material was also used in inter-professional learning initiatives at 15 schools. A variety of approaches were used to assess learning, including: pass/fail (based on attendance), examination (frequently described in relation to bioethics teaching), feedback and production of scholarly, reflective and creative work.

In 15 schools, MD faculty with an interest, and some who had a degree, in the humanities were involved in MH teaching. In all schools, clinical faculty in other health professions, PhD scholars and artists were involved. MH-related faculty development was offered at 11 schools (see Appendix В—Table A36.2).

A variety of funding sources supported MH teaching (Appendix В—Table A36.2). At all schools, internal University Medical Education (UME) funding supported mandatory MH teaching such as bioethics. At a few schools, faculty' positions and infrastructure supporting humanities teaching and related activities had been secured through internal, and/or endowed funding. Several informants shared that they struggled to obtain funding for elective and other curricular and co-curricular offerings (several reported donating their own funds). Many, including those with more established infrastructure in place, described the need to fundraise and secure external research and programme grants.

Appendix C (Table A36.3) summarises co-curricular MH opportunities that our key informants identified at their medical schools. These included: ongoing interest/study groups (n=14 schools), research opportunities and awards/contests (n=13), lectures, workshops and conferences (n=12), student blogs, publications (n=10), and performances, art shows, etc. (n=7).

Twenty-three out of 26 of our key informants indicated they would be interested in contributing to a centralised Canadian MH teaching repository'.

At the heart of it: tales from the field

Key informants who were interviewed agreed that MH teaching is important in educating effective and caring physicians, resulting in better patient outcomes, though their views differed regarding the extent to which this occurred ‘intrinsically’ (promotion and protection of empathy) or ‘extrinsically’ (enhanced analytical ability' and capacity for critical reflection). Additional MH contributions were suggested, including enhanced understanding of marginalised or vulnerable patients and communities, development of the senses/close noticing (e.g., visual literacy), enhanced capacity' for critical reflection, enhanced understanding of the history' and culture of medicine and the provisional nature of knowledge, increased creative problem-solving, tolerance of ambiguity, broadening perspective/worldview, recognition of professional challenges and better self-care.

Other themes identified across key-informant interviews are described below.

Theme 1: successes and challenges

Key' informants viewed the introduction of enhanced MH curricular offerings and contributions over the past decade as an important accomplishment. Examples include: introduction of reflective portfolios, creation of humanities certificates, contributions to curricular reform, introduction ot MH curricular themes, inter-professional learning opportunities and faculty development. Increasing engagement with the broader community was also viewed as an important advance.

Successful introduction of small-scale MH innovations, which were valued by others, and viewed as benefitting the medical school, was associated with the expansion ot MH teaching. One participant shared: “We believe our work facilitated the successful accreditation process at our school!” Another shared that MH offerings at the school were profiled when prospective students came for admission interviews.

The support of students, as well as faculty champions and curriculum leads who understood the contribution of humanities teaching, was noted as integral to the uptake and expansion of MH offerings. A number of interviewees shared that creation of dedicated MH faculty positions and programmes had helped to expand MH networks and curricular offerings at their school.

Annual conferences and leadership fora in the humanities and social sciences, including the ‘Creating Space’ pre-symposia at the Canadian Conference on Medical Education (CCME) since 2011, were considered a significant advance. A number of interviewees mentioned the ‘White Coat, Warm Art’juried art exhibit (Courneya 2011) at the annual CCME meeting as an important accomplishment.

Documentation of successful MH innovations included: creation of new course materials, formal and informal student evaluations, certificates of distinction and teaching awards, annual reports, media coverage, successful funding applications, scholarly presentations and published papers (by both students and faculty).

Challenges included: ongoing perceptions of marginalisation, lack of consensus regarding the MH field, competition for curricular time, limited funding and unrealistic expectations of humanities-based scholarship. Additional challenges included geographic distance between medical schools and arts and humanities faculties (at some universities), lack of recognition of humanities contributions in academic promotion, turf wars between disciplines and the lack of a central repository of educational modules and resources.

Theme 2: medical students and medical humanities teaching

Medical student involvement and leadership in this area were emphasised. When asked how medical students at her school responded to MH teaching, one key informant responded: “Enthusiastically. And the reason I say that is almost every time we have introduced something new on the horizon of arts and humanities in medicine, we’ve been overwhelmed with the response.” One respondent made reference to the bell curve: “15% love it, 15% hate it and 70% are open to seeing the value.” Another informant hypothesised that the few students who provide strongly negative evaluations to humanities exercises were likely those most challenged by it.

Many key informants shared examples of medical students who were active in advocating for humanities teaching, and creating MH resources and curricular and co-curricular offerings. One shared that students at his school were starting a “student-run ‘Arts and Humanities’ journal. They have their first call for submissions out. They’ve invited students from the schools of nursing and pharmacy and human genetics . . . I’m quite excited.”

Theme 3: moving forward

Key informants were keen to share their ideas for promoting MH teaching in the curriculum. Some favoured a ‘soft’ approach—enticing students with content they love:

With medical students. . . it you’ve got a core group who say this is not completely crazy, they can be highly influential with their peers . . . Students are a powerful motivator. They can be your best advocates more than you can ever be as an individual.

Advocating a proactive approach, another informant shared:

You have to get onto the curriculum committee . . . and you have to be persistent.

You might very well be told no the first time, but you go around and you get it later by a different route. Y ou have to keep working hard to get stuff in the curriculum, and then once you’ve got it in, you’ve got to defend it.

Recognising the broad network of influences involved in curriculum innovation and change, most advocated a flexible approach, making use of different strategies depending on the situation. One key informant shared the following example:

We had the portfolio course first and then a monthly narrative medicine group for faculty, and they energised each other. Really engaged portfolio mentors came from that study group. This led to paying attention to the patient voice and organising a community event/partnership at the public library about that.

As for advancing MH teaching, continued opportunities to meet with others at national and local medical education meetings were viewed as vital. Increasing collaboration between humanities scholars with ‘critical depth’ and physicians who have ‘clinical insight to make it relevant to medical students’ was also recommended.

 
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